Caroline Anderson - And Daughter Makes Three

‘Then give me a chance to convince you. What’s the first case?’

He dropped his feet to the floor and stood up, stretching wearily and kneading the back of his neck with one large, long-fingered hand. ‘Here.’ He snapped some X-rays up onto the light box and stood back. ‘What can you tell me about this?’

‘Ouch,’ she murmured.

‘Would you care to be more specific?’ he said drily.

‘Sure.’ She pointed to the radiograph of the right thigh and indicated a long, diagonal fracture of the shaft of the femur. ‘This, obviously, and also here.’ She moved her finger up to the femoral neck, where it angled across to the pelvis. ‘There’s a slightly impacted fracture here, and the hip joint’s gone on the other side, I think,’ she murmured, looking at the other plate of the left side. She peered more closely at it, and frowned. ‘Is there another view of this?’

He snapped it up onto the screen and she nodded. ‘Yes. The pelvis has a slight fracture across the acetabulum, here—’ she pointed out the fine line across the socket of the hip joint ‘—and the whole joint has probably destabilised a little in the collision.’

‘Collision?’

‘Oh, yes, I think so—hasn’t the patient been involved in a car accident? Looks like a telescoped front end, with the bulkhead pushing up against the knees and transmitting the force of the impact through into the thighs and pelvis. I expect she was on the left side of the car and the pelvic fracture resulted from her being slammed against the door or the door slammed against her by another vehicle, perhaps? Were there any other injuries?’

‘Such as?’

She shrugged. ‘Foot or lower leg? Facial? Whiplash to the neck and upper spine? Ribs, maybe, if she was the driver, but I don’t think she was.’

‘She?’

‘Yes, it’s a woman,’ Frankie said confidently. ‘You can tell from the pelvis—and the name on the X-ray plate!’

His mouth twitched and she felt a ripple of relief. At least he appeared to have a sense of humour in there somewhere!

He nodded thoughtfully and answered her previous question. ‘Yes, there were some minor facial and cervical spinal injuries and bruising from the seat belt. The other leg was all right. She was a passenger, travelling on the left of the car in a front right quarter impact. The car then slewed round and hit a wall. The driver was killed outright; so was the rear-seat passenger behind him who wasn’t wearing a seat belt. She was lucky to get away with it so lightly.

‘So,’ he said, leaning back against the desk and bracing his hands on the edge at each side, ‘how would you deal with her?’

Frankie chewed her lip slightly. ‘I’d fix the femur internally, both because it’s a spiral fracture and unstable with traction alone and because the neck of the femur looks stable and I wouldn’t want to go and tug on it. At the moment it isn’t displaced so I’d want to manage it conservatively if possible and just watch it.

‘Also I’d put the other leg in traction to relieve pressure on that acetabulum and rest the damaged tissues in the hip joint.’

‘Just like that.’

‘If the skin’s intact or in good enough condition for the operation and if the soft tissues aren’t too badly damaged. I can’t tell that, of course, from the X-rays.’

‘No. Right, well, she’s our first customer.’

‘And?’

He raised an eyebrow. ‘And what?’

‘Was I right with the treatment?’

A grudging smile touched his eyes. ‘Yes, you were.’

She had to stop herself forcibly from heaving a sigh of relief. Instead she turned to the pile of X-ray envelopes on the desk. ‘What’s next?’

He took down the woman’s X-rays and put them away, then snapped another set up onto the screen. ‘This man.’

He sat back on the edge of the desk again, and Frankie could feel his eyes boring into her. ‘Um —he’s got lower leg fractures—ah—is that an old one?’

She swivelled round to look at him and he shrugged nonchalantly. ‘You tell me—you’re the diagnostician.’

She stifled her retort, turned back to the plates and nodded, running her fingertip down the shin bone and the finer bone—the fibula—beside it. ‘Yes—there’s an old non-union of the tibia, a mal-union of the fibula and another fracture of the tibia and fibula higher up, a new one this time. Looks like a fracture from a direct blow, and as one end of the tib’s free it’s probably caused havoc in the soft tissue.’

‘“Havoc” is putting it mildly,’ he told her, shrugging away from the desk and coming to stand behind her. ‘He was a pedestrian. He was hit by a car bumper at this point—’ His arm reached round her and as he carried on describing the result of the impact his finger pointed out the area of soft tissue damage, invisible on the X-ray.

It would have been invisible to Frankie anyway, because she was suddenly, chokingly aware of him, of the enticing smell of his skin lurking under the smell of antiseptic, the warmth of his arm against her shoulder, the lean, sinuous forearm dusted with dark curls so very, very close to her face …

He muttered something under his breath and moved away, and she released the block of air trapped in her lungs, letting it out on a long, silent sigh, and focused on the X-ray again.

‘So what are you intending to do with him?’ she asked in what she hoped was a normal voice.

‘Open up the leg at the sight of the old fracture, repair the soft tissue damage and realign the old break, pack it with slivers of bone and put an external fixator on to hold the whole thing. I can’t fix it internally because of the risk of infection with the soft tissue injuries, so we’ll put screws into all the various fragments, pull them out into line with a little judicious twiddling, and fasten the whole lot onto a rod outside his leg and let it get on with it.

‘Hopefully the old one’ll heal this time, and the new one’s got two chances. I’m not so worried about the fibula; I want to sort the tibia out once and for all.’

He flicked off the light, returned the plates to the envelope and gestured towards the door. ‘Shall we go? They’re all prepped up and ready for us.’

Watching him operate was a joy. He was careful, precise and meticulous, and Frankie realised with a surge of humility how much she had to learn. Oh, she knew the theory—she’d studied it endlessly—but it was nothing compared to watching the real thing.

And he made it look so easy! Fixing the femur with an intramedullary nail driven down inside the bone had always sounded fairly brutal. In his hands it became a skilled procedure, using imaging techniques to see the nail slowly descending through the femur until it reached the fracture, then the ends aligned so that the nail continued on down the second section.

Finally they were fixed in place with screws through the bone into the nail, and so the bone was held, unable to rotate or slip, with the ends in perfect alignment, and all without disturbing the break in the neck of the femur.

He checked on the image intensifier to ensure that all was as he wanted it, then closed the wound on the thigh and at the top of the femur and straightened up with a sigh.

‘Thank you, everyone,’ he murmured, and turned to Frankie, peeling off his gloves and dropping the mask down off his face. ‘How about a cup of coffee while they prepare the operating room for the next onslaught?’

‘Sounds good.’

She followed him out, accepted the cup and listened as he talked to the anaesthetist, Peter Graham. From the conversation she gathered that this was far from the first operation they had performed in the last few hours, and there were at least two more ahead—the man with the fractured lower leg and another new admission from A and E.